Quality Advisor

2025 Wisconsin Association for Healthcare Quality (WAHQ) Conference

Theme: Quality and Safety Across the Continuum of Care

When: Oct. 17, 20215

Where: Glacier Canyon Lodge, Wilderness Resort, Wisconsin Dells

Join us for the Wisconsin Association for Healthcare Quality (WAHQ) Annual Conference at Glacier Canyon Lodge, Wilderness Resort. As a longtime member and current President-Elect, Jill Lindwall, WHA Quality Director is excited to share what promises to be one of our most dynamic events yet!

Early bird and group discounts: Take advantage of early bird and group discounts—perfect for teams.

Call for Posters: Showcase your quality improvement work and highlight the work you and your teams are doing to improve care.

Featured Session: Hear from three nationally respected leaders in workforce well-being as they spotlight their transformative work, aligned with Caring for Wisconsin’s Caregivers—an exciting, five-year statewide initiative led by WHA in partnership with Advancing a Healthier Wisconsin (AHW) and the Dr. Lorna Breen Heroes’ Foundation. This effort equips health systems with tools to reduce burnout, enhance staff satisfaction and drive lasting change.

Be part of the momentum. Click for more information and to register.

Featured speakers:

Mila L. Felder, MD, FACEP

Vice President, Teammate Well Being, Advocate Health

2021 Well-being Director of the Year, American College of Emergency Physicians

Dr. Felder leads enterprise-wide well-being and peer support efforts across Advocate Health’s 165,000+ team members. A practicing Emergency Medicine physician, she has a launched peer-to-peer support program, co-chaired a systemwide well-being micro-grant series, webinar series and led Advocate credentials changes resulting in recognition by DLBHF in North Carolina and Wisconsin. Her work centers on building resilience, connection and purpose in high-stress health care environments.

Alicia Pilarski, DO

Chief Well-Being Officer, Froedtert & Medical College of Wisconsin

Dr. Pilarski is a nationally recognized leader in clinician wellness. She helped establish Froedtert & MCW’s Peer Support Program and serves as Medical Director for Supporting Our Staff (SOS). She also founded the Emergency Medicine Wellness Committee at MCW and co-authored Resident Well-Being: A Guide for Residency Programs. Her insights on resilience and peer support have been featured in podcasts by Becker’s Hospital Review and the American College of Physicians.

Mariah Quinn, MD, MPH

Chief Wellness Officer, UW Health

Dr. Quinn leads strategic efforts at UW Health to embed workforce well-being into daily operations and culture. Her initiatives include enhanced parental and lactation support, a peer support and critical incident response program, leadership development, improved orientation and belonging and operational efficiencies like AI scribes and team-based care models. Her work supports daily workflow improvements and long-term cultural transformation.

CMS Issues Hospital Inpatient Prospective Payment System (IPPS) Final Rule for FY 2026

The Centers for Medicare & Medicaid Services on July 31 issued a final rule that would increase Medicare IPPS rates by a net 2.6% in fiscal year 2026, compared with FY 2025, for hospitals that are meaningful users of electronic health records and submit quality measure data.

CMS makes a number of changes to its quality reporting and value programs. Among other updates, the agency finalizes its proposal to remove the Health Equity Adjustment from the Hospital Value-based Purchasing program and removes four measures from the inpatient quality reporting program. The agency also will include Medicare Advantage patients in calculating hospital performance in the Hospital Readmission Reduction Program but has not finalized its proposal to include payment data for these beneficiaries in the calculation of excess readmissions.

From The Joint Commission: New and Revised Obstetrical Services Requirements

The Joint Commission has approved new and revised requirements for critical access hospitals and hospitals that align with updated U.S. Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) related to obstetric care.

The new and revised requirements address a CMS final rule published on November 27, 2024. The final rule includes changes for emergency services and discharge planning CoPs and a new obstetrical services CoP. The new Joint Commission requirements that align with the obstetrical services CoP will replace Joint Commission’s maternal safety requirements, which were previously in Provision of Care, Treatment and Services (PC) Standards PC.06.01.01 and PC.06.03.01 for hospitals.

Wisconsin Dental Pain Protocol (WDPP)

The Wisconsin Hospital Association (WHA) participates on the WDPP Advisory Committee as part of the CDC-funded initiative, Overdose Data to Action in States (OD2A-S). This five-year cooperative agreement, launched in September 2023, addresses the evolving and complex nature of the drug overdose crisis. It emphasizes the importance of a comprehensive, interdisciplinary public health response.

The vision for a statewide strategy began several years earlier, however, initial pilot projects have centered on collaboration between Wisconsin emergency departments and their local dental practices. These efforts aim to develop patient-centered treatment plans specifically for managing non-traumatic dental pain. To aid in the expansion of these tools, the WDPP website has launched. This site will be the definitive source for a systemic approach to treating non-traumatic dental pain, assuring ideal pain control practices, supporting antibiotic stewardship and reducing recidivism for oral pain. The first section, Implementation Tools, contains operational resources, including brief videos and documents to secure organization and community buy-in, identify leaders, train providers, set up referral processes, monitor progress, launch and maintain the WDPP. The second section, On-Shift Clinical Tools, contains short videos and reference documents supporting real-time support for diagnosis, non-opioid and opioid pain control, local anesthetics and antibiotics.

2025 Global Vision Community Partnership Award

Do you have a community initiative that your hospital partners with? Would you like grant funding and state-wide recognition for this successful program and partnership? WHA Foundation is proud to offer the opportunity once again for WHA member hospitals to submit a nomination for the annual Global Vision Community Partnership Award.

Nomination Deadline: Friday, August 15, 2025

The Global Vision Community Partnership Award was established in 1993 by the Wisconsin Hospital Association (WHA) Foundation. The Award's goal is to provide recognition, financial support and public awareness of a community health initiative or project, created in partnership with a WHA member, that successfully addresses a documented community health need. Partnerships mush reach across the community or population served, and the program must be an active ongoing enterprise at the time of the nomination.

In addition to a plaque of recognition, the two winners also receive an unrestricted grant of $2,500 each to continue to fulfill their work and mission. Please email Leigh Ann Larson if you have any questions.

Member Recognition    

Wisconsin’s Critical Access Hospitals Earn National Recognition for Quality Performance

Wisconsin’s Critical Access Hospitals (CAHs) ranked among the top ten nationally for statewide quality reporting and performance, as recognized by the Health Resources and Services Administration (HRSA). This recognition reflects Wisconsin CAHs' strong participation in the Medicare Beneficiary Quality Improvement Project (MBQIP)—a key component of the Medicare Rural Hospital Flexibility (Flex) Program.

MBQIP measures span several priority areas, including:

• Patient safety: influenza vaccination among healthcare personnel and antibiotic stewardship,
• Patient experience: through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey,
• Emergency department care: including transfer communication (EDTC) and outpatient metrics (OP-18 and OP-22),
• And soon, new focus areas such as CAH quality infrastructure and care coordination.

For over two decades, Wisconsin’s CAHs have led efforts in voluntarily reporting quality data through the state’s CheckPoint database, reinforcing a culture of transparency and continuous improvement. By publicly sharing quality measures, these rural hospitals drive local initiatives that enhance patient safety and care outcomes.

For more information, contact WHA Chief Quality Officer Nadine Allen.

Wisconsin Named Top 10 State for Health Care in 2025

On July 28, a new WalletHub study released a report highlighting Wisconsin as one of the top states for health care. The ranking, Best & Worst States for Health Care (2025), compared all 50 states and the District of Columbia across three categories: Cost, Access and Outcomes. These categories were evaluated using 44 measures, including the cost of a medical visit, wait-times for services, providers-per-capita and the share of patients readmitted to hospitals. Wisconsin landed among the best in the nation thanks to strong marks in access, quality outcomes and affordability.

Columbia St. Mary’s Hospital Achieves Level 1 Geriatric Accreditation

Ascension Columbia St. Mary’s Hospital — Ozaukee Campus has become the first hospital in Wisconsin to achieve Level 1 Geriatric Emergency Department Accreditation from the American College of Emergency Physicians.

For details about this accreditation, see Ascension Columbia St. Mary’s Hospital — Ozaukee's press release.

U.S. News Announces 2025-2026 Best Hospitals

On July 29, U.S. News & World Report, the global authority in health care rankings and ratings, released the 2025-2026 edition of Best Hospitals, the 36th year of this annual study.

The 2025-2026 edition of Best Hospitals includes the regional evaluation of hospitals at both a state and metro level. This year, U.S. News recognized 504 Best Regional Hospitals across 49 states and 95 metro areas that have demonstrated superior outcomes.

Congratulations to our Wisconsin hospitals recognized on this list!

UW Health University Hospital, Madison, WI | Ranked #1 in Madison

Aurora St. Luke's Medical Center, Milwaukee, WI | Ranked #1 in Milwaukee

Froedtert Hospital and the Medical College of Wisconsin, Milwaukee, WI | Ranked #2 in Milwaukee

Mayo Clinic Health System-Eau Claire, Eau Claire, WI

SSM Health St. Mary's Hospital-Madison, Madison, WI | Ranked #2 in Madison

Aurora Medical Center-Grafton, Grafton, WI | Ranked #3 in Milwaukee

Aspirus Wausau Hospital, Wausau, WI

Ascension Columbia St. Mary's Hospital-Milwaukee and Ozaukee Campuses, Milwaukee, WI | Ranked #4 in Milwaukee